Tooth Extraction

Updated: Apr 4, 2013

Overview
Background
Tooth extraction is linked to dentists who perform oral surgery. Teeth that are
embedded in bone (eg, impacted or wisdom teeth) must be removed by an
oral and maxillofacial surgeon who is trained for 4-6 years after obtaining a
dental or medical degree.
Compared with removal of an impacted tooth, tooth extraction appears to be a
relatively simple technical procedure. However, both tooth extraction and
removal of an impacted tooth must be performed in accordance with surgical
principles that have evolved from both basic research and centuries of trial
and error. Tooth extraction leaves a surgical wound, which has to heal.
Accordingly, a basic understanding of wound healing is essential for
performing this surgical procedure in the oral cavity.
Like any other minor surgical procedure, tooth extraction requires careful
medical evaluation of the patient. Patients with diabetes, hypertension, renal
disease, thyroid disease, adrenal disease, or other organ disease must be
treated and their disease controlled before tooth extraction. Because the oral
cavity is full of microorganisms, any surgical procedure in this area may give
rise to postoperative infection, especially in immunocompromised patients.
Before, during, and after tooth extraction, pain management is an important
issue. Medical, surgical, and legal considerations exist; for example, removing
the wrong tooth is malpractice, as is breaking the jaw during extraction or
causing paresthesia after extracting the mandibular third molar in close
proximity to the inferior alveolar nerve without proper informed consent.

Indications

Teeth are important for aesthetic purposes and for maintaining masticatory
function. Accordingly, all efforts to avoid tooth extraction must be exhausted
before the decision is made to proceed with removal of a tooth. Nevertheless,
there are circumstances in which it is clear that a tooth must be extracted,
such as the following:

A tooth that cannot be restored, because of severe caries

A mobile tooth with severe periodontal disease, pulp necrosis, or

periapical abscess, for which root canal treatment is required that the patient
cannot afford (or for which endodontic treatment failed)

Overcrowding of teeth in the dental arch, resulting in orthodontic

deformity[1]
Other conditions that may necessitate extraction include the following:

Malposed teeth causing soft tissue trauma to the cheek

Cracked teeth from trauma

Supernumerary teeth

Teeth adjacent to a pathologic lesion that must be excised

Planned radiation or intravenous (IV) bisphosphonate treatment,

warranting prophylactic extraction

Teeth in the line of fracture

Aesthetic considerations (eg, teeth with endogenous staining)

Economic considerations (eg, teeth for which extensive restoration is

required that the patient cannot afford[2] )

Contraindications
There are few contraindications for tooth extraction, and most of those that do
exist can be modified by additional medical consultation and treatment. Some
contraindications can be so severe that extraction should not be performed
until the severity of the medical condition has been resolved.

Essentially, contraindications may be divided into local and systemic. Local

contraindications are limited to the extraction sites. An example is an
extraction site that was heavily exposed to radiation; if extraction is performed
in the irradiated area, osteoradionecrosis results. Other local contraindication
is proximity to a malignancy; extraction in the area of malignancy may
increase the chances of dissemination of malignancy.
Extraction may be contraindicated in an area of infection that has not been
adequately treated (eg, an impacted third molar associated with pericoronitis
that is not treated with an antibiotic). Extraction may also be contraindicated
when it is adjacent to the site of jaw fracture, because the teeth may be
required for stabilization of the fractured bone. If the patient has very limited
mouth-opening ability, extracting a tooth may be extremely difficult because of
limited access to local anesthesia.[3]
A systemic contraindication systemic bisphosphonate therapy for malignancy.
Extraction in patients receiving such therapy results in osteochemonecrosis,
which is more severe than osteoradionecrosis and is more difficult to treat.
Other systemic contraindications include brittle uncontrolled diabetes, endstage

renal

and

liver

disease,

uncontrolled

leukemia,

lymphoma,

hypertension, cardiac dysrhythmias, and cerebrovascular accidents.

Pregnancy is a relative contraindication in the first or last trimester; extractions
are deferred until after childbirth. Hemophiliac patients and those with severe
platelet disorders or other bleeding diatheses should undergo extraction only
after these coagulopathies have been corrected. Caution and extreme care
are required before extraction in patients on long-term corticosteroids,
immunosuppressants, or cancer chemotherapeutic agents.[4]

Periprocedural Care
Equipment

Tooth extraction is performed either in a dental office by a dentist or in an oral

surgery suite by an oral and maxillofacial surgeon. In either case, the suite is
equipped with dental chair and a good source of operating light. The chair
provides stability and support and affords the surgeon maximal control of the
force being delivered to the patient through the dental forceps. The chair tilts
to allow appropriate positioning for maxillary and mandibular tooth extractions.
[5]

The oral surgery tray is equipped with surgical instruments for soft tissue,
such as the following:

No. 15 scalpel

Dean scissors

Needle holder

Curved hemostat

Minnesota retractor

Right-angle Austin retractor

Weider tongue retractor

Seldin retractor

Molt periosteal elevator

Suction tip

Adson tissue forceps

Allis tissue forceps

Double-ended curette

Small half-circle needle

Suture materials
Other instruments included in the tray are for hard tissue, such as the
following:

Blumenthal rongeur forceps

Bone file

Burs

Handpiece

Hall drill
In the past, a chisel and mallet were used to remove bone and teeth; currently,
however, the use of these instruments is limited to removal of excess bone.
Additional instrument are also included, such as rubber bite blocks and a Molt
mouth prop, which are designed to hold the mouth open during extraction.
The key instruments used for extraction are also included in the tray. These
may include small and large straight dental elevators (see the image below),
left and right triangle-shaped elevators, a Crane pick elevator, a root tip pick,
or an apex elevator.

Use of straight elevator.

Other important extraction instruments are the various dental forceps

designed for extracting maxillary and mandibular teeth. Maxillary instruments
include the No. 150 universal forceps, which is designed for extracting
premolar and molar maxillary teeth (see the image below), the No. 53 right
and left forceps, which are designed specifically for maxillary molars, and the
No. 1 maxillary forceps, which is designed for extraction of maxillary incisors
and canines.

No. 150 maxillary universal forceps in place.

Instruments designed for extracting mandibular teeth include the No. 151
universal mandibular forceps, the Ash forceps, and the cowhorn forceps (see
the images below).

Lower

universal

Cowhorn forceps No. 23.

forceps

No.

151.

Ash

forceps.

Patient Preparation
Patient preparation includes adequate anesthesia and appropriate positioning.

Anesthesia
Local anesthesia is required for tooth extraction. It achieves loss of sensation
by blocking action potentials and nerve conduction.[6] Local anesthesia to the
regional sensory nerves supplying the teeth eliminates pain, including that

related to temperature and touch, but does not anesthetize the proprioceptive
fibers of the involved teeth. For this reason (as well as out of anxiety), patients
feel painful pressure during extraction. Consequently, many extractions are
performed with local anesthesia along with intravenous (IV) sedation and
inhaled nitrous oxide.
Local anesthetic agents commonly used in dentistry belong to either the ester
group (eg, procaine) or the amide group (eg, lidocaine). Local anesthetics of
the ester group are metabolized by plasma cholinesterase, whereas those of
the amide group are metabolized in the liver by microsomal enzymes. Other
local anesthetics included in the amide group are mepivacaine and long-acting
bupivacaine.
Several local anesthesia techniques are used in the maxillary and mandibular
regions. Maxillary techniques (see the images below) include the following:

Single tooth - Local infiltration or supraperiosteal injection is achieved

for a single tooth by inserting the needle in the mucobuccal fold adjacent to
that tooth

First, second, and third molars - Posterior superior alveolar nerve block
anesthetizes the maxillary first, second, and third molars and the buccal
mucosa surrounding the teeth; the needle is inserted above the second
molar superiorly and medially at a 45 angle to the occlusal plane

Maxillary nerve block - This is performed via the high maxillary

tuberosity approach or through the greater palatine foramen; it anesthetizes
all maxillary teeth, the surrounding bone and mucosa, the lower eyelid and

nose, and the upper lip ipsilaterally

Insertion of local

anesthesia needle into mucobuccal fold.

placement of local anesthesia needle.

posterior nerve block (arrow).

Supraperiosteal

Direction of superior

Maxillary division nerve block.

Highlighted area is anesthetized by maxillary division nerve

block.

Mandibular techniques (see the images below) include the following:

Inferior alveolar nerve block - This anesthetizes all mandibular molars,

premolars, canines, and incisors ipsilaterally, including lingual mucosa; the
needle is inserted from the opposite side, parallel with the occlusal plane,
into the pterygomandibular raphe at the medial side of the mandible toward
the mandibular foramen, which is located midway between the external
oblique ridge and the posterior ramus

Long buccal nerve block - This anesthetizes the buccal mucosa

ipsilaterally, with the needle inserted into the retromolar region; it is usually
given with the inferior alveolar nerve block

Mental nerve block - This anesthetizes the premolar, canine, and incisor
teeth ipsilaterally; the needle is inserted in the mucobuccal fold toward the
mental foramen, which is located between and inferior to the 2 premolars

Highlighted area where injection of inferior alveolar nerve

takes place.

block.

Direction of needle for inferior alveolar nerve

Site of needle insertion for long buccal nerve block.

Insertion of needle in mucobuccal fold for infiltration of

incisor teeth.

Highlighted area is anesthetized by local

mandibular infiltration.

As indicated above, local anesthesia alone may not be adequate for an

anxious patient who may require additional sedation with inhaled nitrous oxide

and oxygen. In the extremely anxious patient, IV sedation with midazolam and
opioid analgesia are used.

Positioning
The surgeon and the patient should be positioned in such a way that the
patient is comfortable and the surgeon can stand or sit in front of the patient
without undue strain. Ideally, the surgical instruments (especially the needle)
should be placed out of the patient's sight (usually behind the patient but close
to the surgeon).
For mandibular extraction, the positioning is as follows:

Chair axis - The chair is positioned so that the mandibular occlusal

plane is parallel to the floor

Chair height - The chair is lowered to afford the surgeon the leverage
and control needed for the extraction

Patient head - The patient is asked to turn the head toward the operator

Operator - The operator is at the 9 o'clock position relative to the patient

Second hand operator - The second operator is at the 3 o'clock position

to help the operator in retracting the cheek, lip, and tongue and stabilizing
the jaw

Assistant - The assistant places the suction tip in one hand and the soft
tissue retractor in the other (and also helps with irrigation when needed)
For maxillary extraction, the positioning is as follows:

Chair axis - The chair is tipped backward so that the maxillary occlusal
plane is at an angle of about 60 to the floor

Chair height - The chair is lowered to the height of the operator's elbow

Patient head - The patient is asked to lift the head and turn toward the
operator for access and visualization

Operator - The operator is at the 9 o'clock position relative to the patient

Second hand operator - The second operator stands or sits at the 3

o'clock position and helps with retraction, suctioning, irrigation, and jaw
stabilization

Technique
Tooth Extraction
For proper extraction of a tooth, the operator must elevate the gingival soft
tissue attachment, luxate the tooth with small and large straight elevators, and
adapt the forceps to the crown of the tooth. Luxation requires apical pressure,
buccal force, lingual pressure, rotational pressure, and tractional forces. The
operator continues to luxate the tooth with the forceps in a buccolingual
direction with slight rotation until the tooth is removed from the socket.[7]
Tooth extraction can be difficult in older patients with dense supporting bone,
dilacerated roots, and broken crowns with extensive caries. Special attention
should be paid to adjacent teeth and vital structures (eg, the maxillary sinus,
the inferior alveolar nerve, and the lingual and mental nerves). To minimize the
risk of pushing the tooth into the maxillary sinus or fracturing the mandible,
extensive force should be avoided.[8] The best and easiest way of managing
tooth extraction complications is to prevent them.
Tooth extraction often leads to root fracture. A small envelope flap can be
reflected to expose fractured roots, and a small straight elevator can be used
as a shoehorn to luxate broken roots. The buccal beak of the forceps can be
used to grasp a portion of the bone at the same time it grasps the root.
The extraction forceps is seated with strong apical pressure to expand the
crestal bone around the root and allow root removal. A small root tip can be
addressed by placing an endodontic file in the root canal and twisting it with a
needle holder. The root can be removed with a No. 4 round bur in a dental
handpiece or a small elevator, which displaces the root from its apex.

Teeth that are liable to fracture during extraction are those with large carious
lesions, those that have been treated by means of root canal procedures, and
those surrounded by dense bone or with ankylosed and dilacerated roots.
Although every effort should be made to remove fractured roots during
extraction, there are some circumstances in which these roots are best left in
place, as when the root is suspected to be on the verge of entering an
anatomic space or when further instrumentation would cause damage to a
vital adjacent structure, would result in uncontrolled bleeding, or might
necessitate an inordinate amount of bone excision.
Extreme care is required in extracting maxillary teeth close to the maxillary
sinus to avoid sinus exposure and subsequent oroantral fistula. Attention is
also needed in extracting mandibular teeth close to the inferior alveolar canal
and mental foramen to avoid paresthesia.

Complications of Procedure
The most common intraoperative complications of tooth extraction are injuries
to the soft tissue resulting from lack of attention to the delicate nature of the
mucosa and the use of excessive and uncontrolled force during extraction;
examples include lip abrasions or burns from a retractor or rotating handpiece.
The next most common complications are injuries to osseous structures, such
as fractures of the alveolar plate in the buccal cortex of maxillary canines,
molars, and mandibular incisors.
The maxillary tuberosity is often fractured during the extraction of a difficult
molar (see the images below), especially a difficult maxillary third molar.[9] This
complication can be prevented by performing a thorough clinical and
radiographic examination and taking care not to apply an excessive amount of
uncontrolled force. Fractured bone in the tuberosity can be carefully dissected
from the tooth with a straight elevator; the bone and soft tissue can then be
sutured in place and the extraction site closed primarily.

Radiograph taken before extraction of second maxillary

molar.

Fracture

extraction of second maxillary molar.

of

maxillary

tuberosity

occurred

during

Maxillary tuberosity was

adherent to extracted tooth.

Radiographically, the layers of the tooth are easily identifiable because they
have different radiopacities. Enamel is the most mineralized of the calcified
tissues of the body, and it is the most radiopaque of the 3 tooth layers. Dentin
is less radiopaque than enamel and has a radiopacity similar to that of bone.

The pulp tissue is not mineralized and appears radiolucent. [10] For more
information about the relevant anatomy, see Tooth Anatomy.
Extracting a maxillary molar tooth close to the maxillary sinus may result in
oroantral communication, which in turn may lead to maxillary sinusitis and the
formation of a chronic oroantral fistula.
Intraoperatively, sinus communication can be detected by performing a noseblowing test to check for passage of air or bubbling of blood in the extraction
site. A small communication (< 2 mm) may close on its own with the formation
of clot and, subsequently, granulation tissue.
A moderate-sized communication (2-6 mm) necessitates the placement of a
figure-eight suture to stabilize the blood clot. Postoperatively, the patient
should be instructed to avoid nose-blowing, violent sneezing, and sucking on
straws. The patient should be placed on an antibiotic for 7 days, a nasal
decongestant for 3 days, and an oral decongestant for 7 days. A larger
communication (> 7 mm) necessitates a flap procedure to close the defect.
Even with meticulous surgical technique, tooth extraction may result in injury
to adjacent vital structures. Lingual nerve paresthesia may result after
injection if the needle passes through the nerve, the distal incision is
positioned too far lingually, or the nerve is cut during lingual bone removal.